Provider Demographics
NPI:1811135718
Name:ELLISVILLE STATE SCHOOL
Entity type:Organization
Organization Name:ELLISVILLE STATE SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-477-5770
Mailing Address - Street 1:1101 HWY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-4443
Mailing Address - Country:US
Mailing Address - Phone:601-477-5770
Mailing Address - Fax:601-477-5895
Practice Address - Street 1:1101 HWY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-4443
Practice Address - Country:US
Practice Address - Phone:601-477-5770
Practice Address - Fax:601-477-5895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865285315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities